Update on the Next Stages of the Review of A Vision for Change: Department of Health

Chairman

I welcome Mr. Hugh Kane, chair of the oversight group to oversee the next stages of the review of A Vision for Change, and Mr. Michael Murchan, assistant principal in the mental health unit of the Department of Health. On behalf of the committee, I thank them for coming and offer my sincere apologies for having asked them to exit quickly earlier. The format of the meeting is that the witnesses will be invited to make brief opening statements, which will be followed by a question and answer session.

Before we begin, I draw the witnesses' attention to the position regarding privilege. Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members should be aware that under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I remind members and witnesses to turn off their mobile phones or switch them to flight mode. Mobile phones interfere with the sound system. I advise the witnesses that any submission or opening statement they make to the committee will be published on the its website after this meeting.

I now invite Mr. Kane to make his opening statement.

Will copies of the opening statement be circulated to members?

Chairman

Did the Deputy not receive one?

No. Could I get a copy please?

Chairman

Sure.

I thank the Chairman.

Chairman

Mr. Kane may begin.

Mr. Hugh Kane

Good morning. I thank the committee for inviting me to attend. As members know, I chair the oversight group that will review A Vision for Change, the national policy on mental health. I am doing this in a voluntary, no-fee capacity and I am not an official in the Department.

The Joint Committee on the Future of Mental Health Care and our oversight group share many of the same concerns. We are both concerned with ensuring that there is a long-term vision for mental health care. We are both aware of the responsibility to meet the mental health needs of all of the citizens of Ireland. Perhaps crucially, we are both aware of the need to ensure that our recommendations are informed by the realities of our mental health services while also balanced by the improvements that we must see forthcoming.

The starting point is the background to both of our discussions, namely, A Vision for Change, which set out a ten-year policy framework for Ireland's mental health services. While its term came to an end last year, its recommendations helped to shape our current mental health system and many of these remain at the heart of effective and appropriate mental health services. The policy proposed an holistic view of mental illness, recognising that biological, psychological and social factors contribute to mental health problems. It proposed a person-centred approach, recognising a need for the voice of the service user to be heard, and highlighted the importance of community and social inclusion in recovery, with interventions aimed at maximising recovery.

We cannot ignore the fact that issues exist within the mental health system. Difficulties in recruiting staff, such as consultant psychiatrists across all specialties and psychiatric nurses, have had a significant impact on the delivery of services. We can also see disparity in the HSE performance reports, with some areas enjoying excellent levels of staffing and low waiting lists while others are not so fortunate. However, it is important to note that progress has been made in implementing many of the recommendations contained in the report. A number of service improvements have been implemented in parallel with the accelerated closure of old psychiatric hospitals and their replacement with bespoke new facilities that are better suited to modern mental health care. Service improvements include the development of adult and child and adolescent mental health services, coupled with shorter episodes of inpatient care, the adoption of a recovery approach in the delivery of services and, crucially, the involvement of service users in service planning and delivery. The importance of working collaboratively with service users and their family members and carers was formally recognised in 2016 with the establishment of the Mental Health Engagement Office within the HSE.

Other ongoing developments include the development of counselling services at primary and secondary care levels, for example, early intervention at primary care level; a greater awareness of fostering mental health promotion in society through campaigns like Let's Talk and #LittleThings; the publication last year of the expert review group report on the Mental Health Act 2001 and the suicide prevention strategy Connecting for Life; a reduction in the child and adolescent mental health services, CAMHS, waiting lists for those waiting more than 12 months, although there is still more work to be done in that respect; and the commencement of work on the new national forensic hospital to replace the Central Mental Hospital in Dundrum.

These achievements are all steps in the right direction. However, in taking any further substantive step towards positive change, we need to first ensure that we are all travelling in the right direction. Any action taken must be evidence based and continue to carry the ethos of person-centred care that was originally espoused in A Vision for Change.

With this in mind, an evidence-based expert review was commissioned by the Department of Health in September 2016 from the Work Research Centre. This evidence review examined the implementation of A Vision for Change and considered how future policy and services might be better directed. The review was completed in February and provides evidence to determine the policy direction for a revision of A Vision for Change in terms of international best practice and the experience of implementing the policy. The report covers the following main topics: mental health situation, policy and services in Ireland today; prioritising mental health as a major societal issue; primary prevention and positive mental health; recovery, social inclusion and living well with mental illness; mental health care provision; and mental health system governance and financing. It presents a broad overview and mapping of evidence and developments in the mental health area that may be helpful in guiding policy development and practice. It does not present recommendations. Rather, it provides an unbiased resource from which information can be drawn.

The next step was the establishment of the oversight group to oversee additional policy priorities for mental health based on the outcome of the expert review. I was appointed to chair that group on 18 July and its membership will be finalised by the end of this month. We held an initial meeting of the group on 5 October to discuss our final terms of reference and finalise our membership. Further to this group, we will have a stakeholder consultation and appropriate additional advice and input will be sought throughout the process.

The priorities of the oversight group will include, but not be limited to, the following: primary prevention, early intervention and positive mental health; the integration of care and delivery systems between primary and secondary services; the development of e-mental health responses, which is important for younger people, who are more familiar with this area; workforce planning, forecasting and skill mix, including mechanisms to attract and retain staff; emerging needs of vulnerable groups, people with comorbidities and specialist needs informed by the relevant clinical programme; and the development of research, data and evaluation capability to ensure that the achievement of the best mental health outcomes can be demonstrated within the resources available.

The oversight group will be requested to produce a high-level policy framework that sets out future service priorities. We will submit our report for consideration to the management board in the Department of Health and the Minister of State for mental health and older people, who may subsequently submit proposals to the Cabinet sub-committee on social policy and public service reform for approval. While the work of the oversight group is just beginning, we must ensure that our final recommendations are implementable and achievable. Initially, we will focus on what will be good outcomes that demonstrate a better life for those who access the services. With this in mind, it is planned that a successor policy to A Vision for Change will include a multi-annual implementation plan to inform the allocation of resources in future years. As committed to in the Dáil, the HSE will be directed to develop a multi-annual approach to the development of mental health services.

I would be happy to address whatever questions or comments members may have.

Chairman

I thank Mr. Kane. One of our main reasons for inviting him was to ensure that we did not overlap and were not doing the same job. Members would like to ask Mr. Kane questions. Based on what his group is doing, we will make decisions on how our committee will perform. I will call Deputy Corcoran Kennedy first.

I thank Mr. Kane for his presentation and wish him the best of luck in his work. I commend him on doing it on a voluntary basis. Has his committee decided on the terms of reference yet or has it been given those? Has it finalised its membership and what the skill mix will be?

Mr. Hugh Kane

We have an initial set of terms of reference that are subject to finalisation. If the Deputy wishes, I will read them to for her. Would that be helpful?

Mr. Hugh Kane

We are going to consider primary intervention, early intervention and positive mental health, which is about keeping people well. This is important. We will examine the integration of care and delivery systems between primary and secondary services. We have been asked to consider the development of e-mental health responses as well as workforce planning, forecasting and skill mix, including mechanisms to attract and retain staff. We will consider the emerging needs of vulnerable groups, people with comorbidities and specialist needs informed by the relevant clinical programmes. We will also examine the development of research, data and evaluation capability to ensure that the achievement of the best mental health outcomes can be demonstrated within the resources available. These are the terms of reference that have been drafted.

When we had our first meeting, the oversight group thought we needed to include the needs of vulnerable groups and we should also have an overall policy goal to reduce stigma and enhance resilience. These are being considered for inclusion in the terms of reference by the Minister.

Is there a timeline or deadline in the terms of reference?

Mr. Hugh Kane

We spoke initially of a 12-month period and we hoped that when we scope our work and get going, we will have it finished by the end of next summer. With regard to membership of the committee, we went for a very high-level oversight group with enough skills to ensure we can perform our task. We will rely on bringing in other expertise and views as required. I can give a flavour of the kind of people already on the group. In addition to me as chairman, there is Mr. Liam Hennessy, who is the Health Service Executive's head of mental health engagement, and who describes himself as a patient of the mental health services. We have Dr. Philip Dodd, the national clinic adviser and clinical programme group lead for mental health, a consultant psychiatrist with a special interest in learning disability. Dr. Amanda Burke is an executive clinical director for the Galway-Roscommon mental health services, Dr. Fiona Keogh is a senior research fellow in the National University of Ireland, Galway, and Ms Martha Griffin is an expert who works in Dublin City University as a lecturer. Dr. Shari McDaid is a lecturer in mental health reform, Ms Yvonne O'Neill is head of planning and performance and a programme manager in the HSE, Mr. Leo Kinsella is a HSE area manager, and Mr. Colm Desmond is principal officer in the mental health division of the Department. They are the current members.

I thank the witness. I note there is a good gender balance as well.

Mr. Hugh Kane

Absolutely.

In terms of deliberations, what methodology will be used? There is much evidence available so how will it be distilled so as to evaluate what will inform the policy perspective? How will that fit into the Healthy Ireland framework, which is embedded across all Departments?

Mr. Hugh Kane

Our starting point will be to be really clear about what we want our mental health services to look like and formulate some fairly key outcome measures that will allow us to determine that. If we start from that position and are guided by that vision and those outcomes, we will try to deliver that. We will look at the evidence and expertise that will guide us to delivering the policy. Our hope would be that the policy would set the outcome measures and we would work from that basis. That is instead of coming up with a list of resources required to do something. We are going with what we are trying to achieve in the outcomes first and then trying to match what we need to deliver that. We will also consider evidence in that area. With regard to Healthy Ireland, there will definitely be a focus on trying to prevent people becoming unwell, intervening earlier, building resilience and having a clear focus as we progress. It is a matter for a wider group and we will have cross-departmental and agency support in trying to bring in other stakeholders to achieve that.

It is crucial that the Healthy Ireland framework would be considered carefully as it is where health and well-being are embedded in Government policy. It takes a cross-departmental and whole-of-Government approach, and this is crucial for it.

My next question relates to our new communities. A Vision for Change was published 11 years ago and society has changed enormously since. Our population has increased and we are facing challenges that we never had to face before. For example, there are refugees from countries where they experienced female genital mutilation, and there is psychological damage arising from that, not to mention the appalling physical damage. Will the group be able to build that kind of consideration into its work? We have experienced social changes in recent years, and even in the past six or seven years we have seen an impact from social media on every one of us, never mind vulnerable young people. How will that be built into the consideration?

Mr. Hugh Kane

We have been asked to consider the emerging needs of vulnerable and new groups, so that covers us with respect to the people coming to the country. We will consider e-health response as well and part of that will examine good use as well as negative impacts. We will consider how to ameliorate the problem and work with stakeholders in the area.

I thank Mr. Kane for his presentation and I wish him well in his work. I have a specific interest in certain areas. I worked as a pharmacist before I got involved in politics. I saw a significant increase in the use of medication for children with mental health issues. I have a personal opinion that this is something that must be examined in a radical way, particularly overuse of products, and I often feel that because of the strains on the system, children may be prescribed medication because the time may not be there to deal with issues through cognitive behaviour therapy or more appropriate treatment. We need to investigate the matter and I ask the witness to consider some expertise in that area for the committee.

I would also like the group to examine education and primary education in particular. Children's brain development is most active in those years and well-being and mental health should be almost a compulsory part of the primary education system. It would be a very good starting point for prevention. I have personal experience of children with difficulties having battles for evaluations in schools. They eventually get special needs assistance but can be put into secondary school without any link-up between the schools. The same child with difficulties would go into a new environment, with different challenges completely as secondary school is so different from primary school, and after three months or so behavioural problems would be seen, with people scratching their heads wondering why it happened. The obvious answer is staring us in the face. It is another area we must consider very carefully.

The witness mentioned a multi-annual delivery and implementation plan, which is critical. In this committee we recognised very early that the reports are there but one can never design a perfect system on paper. I would add to the implementation plan an implementation office and a direct line of responsibility for implementation. This is instead of somebody saying it is not his or her responsibility. When somebody has a responsibility to deliver something, it generally happens. It is a key element.

There is also the matter of GP referrals to the child and adolescent mental health services, CAMHS. Is that a guarantee of a timely appointment? It should be but I am led to believe there are difficulties or sometimes it is not recognised the way it should be. I ask the witness to examine that also.

Mr. Hugh Kane

We have already considered some of those matters but any new issues will be taken on board. We will see what we can do. There are many difficulties but we want to bring something that sets the highest standard but which is deliverable. We do not want to set ourselves up for a further fall by over-promising. That is where the multi-annual element comes into effect, as we can step up what will happen over the years and build it in a particular way.

I have a number of questions and will try to ask them as quickly as possible.

I do not want to see the work of this committee running parallel to any other review. There have been too many reviews of reviews of reviews. We already had reports from the psychiatric nurses and the Royal College of Surgeons. We had a review of A Vision for Change and we are talking about another. We have an excellent document from Mental Health Reform containing another review of A Vision for Change. Therefore, we could be going down the wrong path already. Where would Mr. Kane like to see this committee going? I acknowledge that is a very broad and open question. If Mr. Kane were sitting here as a committee member, what would be his number one priority? Would he envisage a timeframe for its implementation?

Deputy John Brassil mentioned education and the schools approach. I certainly agree with that. Page 51 of the mental health reform report, the review of A Vision for Change, which is produced already, contains all this information. It is an exciting document and it will cut out a lot of work for us. I have a note stating prevention in schools should be the key to reducing the stigma and risk of suicide. This would involve a low investment for a very high return.

I do not want this committee to be a talking shop. I want it to be an implementation body that works over each quarter, perhaps. Do we honestly need another review of reviews when all the reviews have been produced by professionals and experts? I have said at a meeting on the Committee on the Future of Healthcare that the experts we have left out of most committees are the 16 and 18 year olds who experienced the traumas, and the people with disabilities. The latter have been forgotten about.

Mr. Hugh Kane

To clarify, we are not reviewing A Vision for Change. What we have been asked to do is develop a successor to A Vision for Change. We are not going to throw A Vision for Change in the bin and just repeat the cycle. There are some elements in it that are still important and relevant. We are going to try to add to them to have a policy that will guide us over the next ten years.

With regard to action and an action focus, I am at a stage in life where I get a bit impatient about talking and chatting. Even in my own family, there is a real burning issue in this area that drives me on. Both professionally and as a father, I have a problem here that I want resolved. I hope to bring that energy and drive to what we are doing. That is why, right at the beginning, the focus was on trying to come up with a set of outcome measures that will really demonstrate an impact on people on the front line.

My immediate priority is ensuring that, if people have difficulties, we are at least able to offer support immediately and to start to move on that basis. Referring somebody to a practitioner who will see him or her in three or six weeks is not sufficient. If people have a really urgent issue, they need to be seen. We need to have a system that is able to achieve this. That is really important.

I take the point on 16 and 18 year olds and the disability sector. As part of a consultation process, we could do something really targeted in this area so we represent the views concerned. This is also really important.

Mental health reform was mentioned. Dr. Shari McDaid is part of our group. Whatever she has done that is of benefit to us will be taken on by us.

I thank Mr. Kane for being very frank. While we spent considerable time today talking about this, we must remember that this committee is a driving committee, not a talking committee.

Mr. Hugh Kane

We hope to mirror that.

I met Mr. Kane before when he was wearing his Genio hat. He is a man of great integrity and experience. I am dismayed, however, that the oversight group is working in parallel with this committee. The group's remit sounds very much like ours, yet we know there are people, including in Mr. Kane's family, in dire straits all over the country. They include children, older people and younger people. Very nicely, the committee secretariat produced a summary of the 48 reports. We have reports, committees, groups and consultations coming out of our ears and we need to get on with a fairly simple task. We know how to do so. I am slightly depressed and dismayed over the state we are in today. Pragmatically, however, there are always opportunities so I am interested in learning how Mr. Kane believes we could work together effectively without tripping over each other. What should the relationship be?

I suggest that it would be helpful if the oversight group were accountable to this committee. Perhaps it is something we might write to the Minister for Health about. In a way, the Minister for Health is the master of us all. This would make sense and it would ensure we are not doing the work the group is already doing. It would ensure, however, that the group's work tracks back to us. How does Mr. Kane envisage us working together? Is he similarly dismayed that we might trip over each other?

I have a suggestion for the Chairman and the other members regarding the worthy work the oversight group will undoubtedly do. The people on the group are very expert and experienced. Perhaps the group could be accountable to this committee.

Mr. Hugh Kane

There is no point in our inventing wheels on each side of the city in our work. We are really delighted to be here this morning, before we get our work under way, so that between us we may be able to work out a way of sharing work and coming together to do stuff, with the group doing one task and the committee doing another. We would certainly be very open to considering how we could do that.

While the work is ongoing, we should continue to drive on and do what is required. Our role is to set out what the agenda will be over the next ten years.

With respect, that is our role, too. That is the reason the committee was established. Mr. Kane and the committee have been asked to address this.

Mr. Hugh Kane

I do not see why, when we are approaching a conclusion or even before then, we cannot share views, with each side enhancing the vision of the other. It is really important that we come up with a united, clear picture on which we can all agree and then get behind it and drive its implementation. As a group, we would be very open to that. We are here today to talk to the committee and work with it on it.

Would the oversight group be willing to be accountable to the committee in some ways?

Mr. Hugh Kane

That may not be a call for me.

The group can work with us.

What about the Minister? As I stated, it seems confusing.

Chairman

May I intervene? Our decision, as a committee, will be made after we hear everything from Mr. Kane and in private. We do have to ask each other where we are going to go with this committee because its remit sounds very similar to that of Mr. Kane.

Before I open the discussion to the rest of the members, may I ask two questions? A Vision for Change has always been about early intervention, particularly primary care. I note that there are no general practitioners in the group. I cannot understand why. Mr. Kane talked about experts. Of course they are experts but, besides Shari McDaid, are they mainly HSE employees? If that is the case, we surely need not only experts who come in to have an input but also a broadening of the group to include general practitioners or other primary care professionals who could advise on what is required.

Is the oversight group rebranding A Vision for Change or producing a brand new document?

One of the concerns of nearly all members is that we are doing reviews over and over again. Mr. Kane stated this strategy is for the next ten years. A Vision for Change was also a ten-year strategy. What will happen ten years from now?

Mr. Hugh Kane

As I indicated, we have not finalised the membership of the group. At our initial meeting, we recognised that we had a primary care gap and we are examining how we will address or fill this gap. We are just an oversight group and part of the challenge at oversight group level is to ensure the team has sufficient competence and is able to weld together to deliver what is required. If we get into members of primary care teams and multidisciplinary mental health teams, we could quickly end up with 25 or 30 people sitting around the table. This would have the potential to slow down the process. We have set up a tight oversight group which has a mix of Health Service Executive and non-Health Service Executive members. The HSE piece was important because when we finish our deliberations, the HSE will have to implement and deliver our conclusions. The reason there are a number of HSE staff involved in the group is to hear their views and secure their buy-in and involvement from the beginning. That is the balance we are trying to strike.

We will have consultative structures, processes and ways of engagement with whatever other expertise we need when dealing with a particular matter. This is a high level group which will oversee the work we will do, rather than just doing the work, if the Chairman understands the difference.

I have not been asked to do a rebrand. As I stated, A Vision for Change is a substantial document, much of which is still relevant. The oversight group must try to identify what new elements need to be added to the strategy to produce a new mental health policy for the next ten years. As I stated, I am impatient and I have no interest in a marketing or rebranding exercise. I am only interested in trying to develop a set of actions which will deliver real change for people who need it.

Chairman

As someone with a background in mental health, I strongly urge Mr. Kane to invite someone from primary care, specifically general practice, to join the group.

Mr. Hugh Kane

I will take that into consideration.

I thank the witness for his presentation. I am sure he will pick up on members' frustration about the lack of implementation. Some of us work at the coalface of mental health and deal with families who have lost loved ones to suicide, which is very difficult.

I strongly welcome the terms of reference, particularly in respect of primary prevention, early intervention and positive mental health. Prevention is fantastic. Senator Kelleher's point on working together is a great idea. We should be working together and partnering up in all walks of life in any case. The political parties should also do a little more of this because cross-party approaches are the way forward.

Were the members of the oversight group selected specifically on the basis of the terms of reference? Do they include, for example, specialists in primary prevention, early prevention and the integration of care and delivery systems?

I apologise to members for raising this issue again but I work in the field of addiction. Recently, the Special Rapporteur on Child Protection, Dr. Geoffrey Shannon, raised the issue of alcohol in the context of child protection. Ireland faces an alcohol crisis. The impact of alcohol misuse on families, particularly children, is devastating, especially in terms of mental health. Is the oversight group considering the issue of children who are reared in homes where there is alcohol misuse and the impact this has on mental health? More than 50% of people who die by suicide have alcohol in their system. We are in a crisis, with three people dying by suicide every day. Alcohol is a depressant which causes severe mental health issues. Every family has someone in their lives who has a problem with alcohol misuse. Is this issue being considered or is the oversight group doing any work involving alcohol misuse?

I thank the witnesses for the report. A Vision for Change is crucial. All of us know people who suffer from depression. On the issue of awareness, will Mr. Kane elaborate on the Let's Talk and Walk and #LittleThings campaigns? I am a firm believer in using campaigns to highlight issues because we need to speak about mental health. It is crucial that funding is provided for campaigns. Awareness is very important because a lack of understanding of mental health issues can be a major problem. People are afraid they may say the wrong thing when speaking to someone with mental illness.

The difficulty in recruiting staff, particularly consultants, is a major issue. People are waiting for appointments and Members of the Oireachtas often make telephone calls asking when appointments can be made for people. How can the issue of recruitment be addressed?

We need to work together because we would be stronger as a team. Being divisive will not work. A Vision for Change was published 11 years ago. The HSE must work with all the different groups and families, in particular, must be included. The submission refers to working with families and different groups and states this was recognised in 2016 with the establishment of the mental health engagement office in the Health Service Executive. Will Mr. Kane provide more information on this office?

I thank the witnesses for their attendance. I appreciate Mr. Kane's enthusiasm and down-to-earth approach. I also welcome his statement acknowledging improvements in services. While there have been some improvements, the reason the committee was established is that there have not been enough improvements and we are committed to improving mental health services.

I tried to note the names of members of the oversight group but I was unable to write all of them down. Will Mr. Kane circulate to the committee a list of the members' names and some background information on them? I noted the names of three doctors, namely, Dr. Philip Dodd, Dr. Amanda Burke and Dr. Fiona Keogh. Are they all psychiatrists or does the group include a psychologist?

I agree it is necessary to have primary care and general practice represented on the oversight group. However, it should also include a nursing representative, either a registered nurse or a physician assistant. As front-line staff, they deal daily with what goes on and should be represented on the group. I appreciate, however, that the group will not be able to function properly if it is too large.

I would like the oversight group to examine the issue of 24-7 emergency admission to mental health units. As we all know, people with mental illness do not always have an episode, as it were, between 9 a.m. and 5 p.m. I know many people who have experienced difficulty accessing emergency inpatient care.

I would also like the group to examine the issue of funding. Significant funding is provided for mental health. Some would argue it is not enough and I accept there is always scope for more money to be provided for all sectors. Funding for HSE mental health services and other organisations doing the same work is allocated to the top of the organisation, so to speak. If, for argument's sake, €100,000 is provided to an organisation, how much of this finds its way down to the service user?

How much of it is lost on the journey? I would love the matter to be considered. I believe a lot of money goes in but I do not believe that all of the money is used on the front line to benefit service users. I do not know if that is something that the group has considered but I would love if it would include the matter in the review. I thank the witnesses for their time and enthusiasm.

Chairman

I call Deputy Neville and he will be the final questioner.

I welcome the witnesses. I wish to express my gratitude to the group's members for their time. I must note that they are here on a voluntary basis and not in a professional capacity.

I welcome the oversight. As Deputy Browne mentioned last week, we do not want this review to reset the policy document, A Vision for Change. We do not want to start from zero again once the review is completed. We are ten or 11 years into the programme and this will be version 2.0. We are simply modernising the programme, as Deputy Corcoran Kennedy said about social media, etc.

We must focus on stigma again. We have taken our eye of the ball, slightly, in terms of stigma. Great work has been done to tackle stigma, particularly as it started from a low base. Ten or 15 years ago I campaigned and canvassed and I can recall that people did not talk about mental health issues when I spoke to them on their doorstep. Thankfully, all of that has changed over ten or 15 years and we now have a specific committee to tackle the matter. This generation must decide what its legacy will be in ten or 15 years' time. If we can start to break down stigma, life will be a lot easier for everybody with these conditions. One can have all of the services in the world but they will not be of any use if people feel that they cannot interact with them. I wanted to specifically stress that matter.

I would like the review to identify easy wins for us in terms of the implementation of A Vision for Change. Where are the quick wins? Often times, in these documents, one has the big and small issues. Where are the easy wins that we can start moving on straightaway?

Along with Senator McFadden, I would like to know whether the review will consider budgets. There is a big lack of knowledge about how the HSE spends the money it is given. I would like to be given a specific breakdown of the figures. One can talk about helicopter and aspirational views but if the budget does not marry them, we will be caught again.

Is an emphasis being placed on using creative arts and sport as part of a recovery model? The initiative is important and needs to be pushed by the committee. I believe this committee will work most towards implementation, as we discussed last week. We must outline an overview of where we want to reach but there are two cogs. First, we are discussing implementation and obviously the review will update same. Part of the committee's remit should be to invite the HSE in here to discuss budgets, to find out where the money goes and to drill down into the details in order to inform the public. I would appreciate the answers.

Mr. Hugh Kane

I will do my best to answer the questions. Senator Black asked about our membership. We tried to pick people for their expertise and thought processes in terms of strategic planning, and for their ability to link that kind of thought with implementation. We sought personal qualities. Some of the people with these personal qualities also have clinical expertise and other insights. Dr. Philip Dodd and Dr. Amanda Burke are our consultant psychiatrists and Dr. Fiona Keogh is a research psychologist. One can see that element in terms of service users. We have people who have the expertise. That is what we tried to bring to the table rather than have a whole group of professional people. We will involve other levels. At that particular level we sought people with the competencies to oversee and drive this work.

Addiction is part of all of the mental health services all of the time. There has been a long discussion on whether addiction is part of the mental health service area or is a stand-alone unit and where it interacts. We have no specific reference to alcohol in our terms of reference but we will discuss the point raised by the Senator. Addiction is there, it is living and it is a big thing right in the middle of the service. We must decide where it belongs and have greater integration.

Senator Murnane O'Connor asked about campaigns. There have been a number of campaigns such as Let's Talk and Walk, which calls on people to reduce the stigma, raises awareness and encourages people to discuss their difficulties. All of us try to live that in our daily lives even coming here today, and that is why I mentioned that this matter is really personal to me. That is me saying, as a dad, that we have a problem. It is important to start the conversation and have campaigns, which is a really good way to do so. The #LittleThings campaign highlights the things one must pay attention to in one's life. Both campaigns were accompanied by publicity campaigns. They emphasise that we all have problems every single day of our lives and provide people with advice on how to manage them. Providing advice and information has been the focus of those particular campaigns.

There are many things going on with the recruitment of staff. Some people say it is money and others say it is something else. Evidence suggests that what really engages people in their work is whether they have a passion for it and are interested in what they do. In terms of the work we are trying to do, the more we empower people who are on the front line to do what they need to, then that is as much an attraction as salary for people. What I have said is a little bit linked with what Senator McFadden said. I wrote the piece because I thought it would prove useful. I did not want to say nothing had happened because sometimes it can have an impact on people who are doing stuff and trying to do things better.

Mr. Hugh Kane

One must acknowledge people. If one keeps telling people they are crap and not doing a good job then it will have a negative impact.

Mr. Hugh Kane

That is why I thought we should give a balanced review. We must say that some things have really been good and there are great people doing super jobs every single day but there are things that we need to sort out as well. We must reaffirm to people that this is difficult work in difficult circumstances but it is really important. Any one of us could need the support of these professionals some day. It is important that we strike a balance.

I have dealt with the query about doctors. I will now respond to Senator McFadden. When we considered the composition of the group, we opted for competency rather than have every single representative group involved at the oversight level. We made that decision and we have tried to apply it to how we do our work and drive that on.

Emergency admission is a thorny issue. People would say that if one has an emergency, no matter what it was, one should go through an emergency department. The initiative was introduced as part of trying to remove the stigma. The initiative has, to a lesser or greater extent, been successful. However, we must consider a 24-7 service.

A number of members have mentioned money and the budget piece but I think we will just flag that. Perhaps people with more expertise than us can address those queries for the members.

We are not resetting the policy for A Vision for Change. We want to build on it and see where we can go from there.

I agree that stigma still impacts on the ability of people to speak about mental health issues. Therefore, if one has a mental health difficulty, other people think it says something about the sufferer rather than something experienced by one out of four of us over a lifetime. I agree with Deputy Neville that attitudes to mental health were very low and the terms "lunatic" and "lunatic asylum" were bandied about. A huge piece of work is necessary to dispel the stigma.

In terms of creative arts and sport to combat mental illnesses, I saw such projects when I worked with the Genio organisation and around the place. I also chair a sports for all group across the major sporting organisations that are considering using sport to assist people to stay well, have a better quality of life and improve people's understanding of mental health and mental health difficulties, and working at a different level around the issues.

I am all for easy wins and things that we can do to make improvements in the area. If we come across something helpful, as we write the report, we will feed it straight back into the system as we go along.

Can Mr. Kane make us aware of them too so we can start pushing it from our side?

Mr. Hugh Kane

Yes. I hope I have not forgotten to respond to anyone.

Chairman

That is fine. I call Senator-----

The question on budgets has not been answered.

Chairman

Mr. Kane said he could not answer that.

Mr. Hugh Kane

We will talk to others who may have expertise on that and we will see if we need to do something on it. The policy we are proposing is to focus on outcomes. Resources and money should be tied to them rather than needing all these people before doing anything. We certainly do not want to be in a position where we cannot do anything until other people are finished or until certain other things happen.

Chairman

The next batch of questions will come from Senator Devine, followed by Deputies Barry, Harty and Catherine Martin.

On a sombre note, I remind members why we are here. My colleague, Deputy Pat Buckley, has just taken his fourth call this week advising that a mother of four young girls has taken her life. That is the fourth one he has experienced in the local area. It is a stark reminder of why we are here. It is to prevent young girls having to grow up without a mother.

We talked about resilience in children in schools and the development of self-confidence and ability from the start, including in crèches. Would it be possible to consider strengthening the role of the nursing and midwifery staff in the prenatal and perinatal period? They assess the pregnant woman's physical health. They have checklists for blood pressure and all that sort of stuff. They also do post-delivery checks for ten days or whatever. They then check the co-ordination, movement and speech. We need to embed emotional attachment to those checklists because even pre-birth it will flag up possible early intervention, possibly pre-birth, that could take place. Having said that, we have not had mother and baby beds in the State for 15 or 20 years. Mothers are separated from their children as soon as they are born if there are difficulties.

I believe Wheatfield Prison carried out a project on the overuse of benzodiazepines, lorazepam and Valium. The prison took a zero-tolerance approach to it and they are not prescribed. As one can imagine, there is a bit of uproar among the prisoners now and again. It has actually worked for the past three years. While I know it is not the witnesses' area, I have a grave concern about the ethics of pharmaceutical companies approaching prescribers and encouraging the dubious use of medication especially for seven to 17 year old children. That may not be in the witnesses' remit but we need to mention those points at some stage.

I thank Mr. Kane for coming to address the committee.

We have a huge challenge. People are in serious need, including people whose health is at stake and people whose lives are at stake; there are huge issues here. I am sitting on this side of the table and Mr. Kane is on the far side. I am a member of this committee, the Joint Committee on Future of Mental Health Care. He is a member of a committee charged with developing a ten-year successor to A Vision for Change. It is not exactly the same. The future of mental health services could be 20, 30 or 40 years. Mr. Kane's remit is for the next ten years. However, there seems to be a massive overlap between what we have been asked to do and what his group has been asked to do. Senator Kelleher pointed out that there have been 48 reports on this.

While I will ask Mr. Kane in a minute, I wish I had the Minister of State sitting across from me so that I could also ask him a question. After 48 reports, what the hell is going on? We are sitting over here and Mr. Kane is sitting over there with remits that seem to be largely the same. It seems to be messing. If I was a member of a family experiencing a mental health crisis at the moment, I would be asking what the hell is going on here and would be asking very sharp questions of the Minister of State about that.

The point has been made that both committees can work away and we can co-operate. Mr. Kane's committee could come up with a report proposing one direction and our committee might come up with a report proposing a different direction. Where would we be then? It is a mess from what I can see.

Mr. Kane's committee was set up ahead of this committee. What was his initial reaction when he heard about this committee being established? When he looked into it, did he see any significant difference between what he has been charged to do and what we have been charged to do? Does he share the frustration about having two committees with what seems to be a broadly similar remit? A key discussion for this group after the presentation and the question-and-answer session is where we go from here. I will leave those questions on the table for now.

I thank Mr. Kane and Mr. Murchan for coming in this morning. I will deal with two practicalities relating to the priorities of the oversight group. One relates to the integration of primary and secondary care, and the other relates to workforce planning and recruitment.

On the integration of primary and secondary care, mental health issues are quite difficult diagnostic issues. So much comes through the door of a GP that it is difficult to sift through what needs to be dealt with outside general practice and what can be dealt with within general practice. There is a quantum leap when moving from general practice to referring on to the psychiatric services, for want of a better word. There are many holistic issues relating to mental health. Is it a disease or just an issue somebody has? We do not want to label people unnecessarily.

There are many social determinants of health, including unemployment, social deprivation, housing, education and social exclusion. Many of the issues that present as mental health issues are not illnesses or diseases and should not be over-medicated. How should we integrate primary care and secondary care? In my local community I am on first-name terms with the staff that exist. Quite often there are many members of the community psychiatric team that do not exist.

I agree with what Deputy Brassil said about over-medication which often arises because other services are not available and it is the last port of call. However, I think there is over-prescription of medication.

Mr. Kane talked about forecasting and workforce planning. What is needed in a community psychiatric service is pretty obvious, namely, social workers, counsellors, psychologists and, of course, psychiatrists. Quite often we are missing the social workers, psychiatrists and counsellors who provide talk therapy and not medication. How can we address the issue of recruitment and retention? Either it is not possible to recruit or there is a rapid turnover from burnout.

I do not think it is salary. It could be workload, job satisfaction, or support from management. Maybe Mr. Kane would address those issues of integrating and recruiting staff and ensuring there is a full complement of staff in each area.

I thank Mr. Kane for coming in and for the work he is doing in a voluntary capacity in chairing the oversight group. Like other members, I had concerns about the overlap when this committee was set up. My concerns remain today and may be even greater. Does Mr. Kane share them? We could say that he is looking at the successor policy, what needs to be done, and that our role may be implementation. However, it is here in black and white that the successor policy to A Vision for Change will include a multi-annual implementation plan. Therefore that is not something we should be doing. How does Mr. Kane envisage us working in tandem?

On the membership of the oversight group, following on from the remarks of Deputies Harty and Brassil on over-medication, is there any intention for the oversight group to examine mindfulness-based cognitive therapy or stress reduction? I would agree with the Chair about having a general practitioner in the oversight group. Would Mr. Kane consider also including an expert in the field of mindfulness or resilience building? These areas came up in our education committee, which produced a document recently on positive mental health in schools.

I agree with other members of the committee on the funding issue. I would ask Mr. Kane to flag it and that it be looked at. It has been an issue with A Vision for Change, even as recently as last week in the budget. We have this great plan but the funding is not delivered to match it. That is a major problem when it comes to implementation.

Mr. Hugh Kane

I acknowledge what Senator Devine said about suicide. It is a huge problem and is the reality of what we are trying to deal with. Suicide very often involves a wider issue than just the mental health services end. We need to keep sight of that. There are lots of things that impact on people's mental health, as the members all know, such as having a good job, a nice place to live, etc. It is a much wider thing.

In terms of the whole medication piece, they are very much practice-based issues and may not be appropriate to a review at our level. We will take the issue back and have a think about it. I think, though, that there is a place for medication, properly supervised and administered, while there is also a need for a whole range of other supports as well. They have to work together. That is very clear.

Deputy Barry spoke about the challenge of what is going on at the moment. There is a huge machine out there as we speak, a range of services being delivered and supporting people. That is going to continue. If there are problems with the delivery of that, they should be addressed as we go along as well. Their work will not stop because we are talking about what is going on at that level.

In Ireland, we are reported to death. There are huge amounts of stuff. I certainly do not think there would be much point in our two groups working independently and coming up with a set of things that are going in opposite directions. There are options there. The oversight group could step down what it is doing and leave it to the committee or we could have more engagement to make sure we are both generally working in the same direction. It is no issue for me. I think we could work together. I have not heard anything here today that is different from what we are thinking. I think we are all ad idem on lots of issues. If we are able to support each other and do a better job, great. If not, let us call it and act on that. As I said earlier, my interest is very personal. I am interested in trying to deal with stuff as we go along.

On the integration of primary care and secondary care, I have some ideas myself. The oversight group is going to look at this issue when we sit down. We will examine the issues, talk to the experts and come up with some pieces that are really helpful. That might include things like training modules and improving training at general practice level, better links between primary and secondary care and between people working on the ground, promoting the kind of multidisciplinary team that expands to include families, general practitioners and whoever else might be able to support someone. It is not always someone on a formal team who can help. Peer support workers, for instance, give fantastic support to people. It is about looking within a community rather than sticking to the usual model of identifying the key people we need. If those people are not available, we have to start looking at alternatives. I think there are people in community groups, peers, who have expertise by experience, and families who can add that kind of support to the professional people who are there. As was said, a mental health problem can often be linked to lots of other things that are going on in people's lives that have nothing really to do with an organic mental health problem. We have mentioned that social things impact on people's work.

I have addressed the question about over-medication. There is a role for medication. If there is over-medication, it is a professional issue. There are clinicians in our group who understand that and we will discuss with them what is the appropriate forum in which to deal with it.

The whole issue of retaining staff is going to be a huge challenge. As I said, it is not just about money. It is about people being valued and supported. It is really important that we try to identify the best ways of supporting people who are doing very difficult work, not just professionally in terms of their practice every day but also just as human beings who are dealing with difficulties. I think that would be really helpful.

Deputy Martin asked about how the oversight group can work in tandem with the committee. I think we can have that discussion. If someone tells us we are not needed, that is something we will take on board. We should be able to work out a way. As I was saying in my previous comments, there is a whole range of different supports there. Mindfulness can be useful as can building resilience. Very often, those who work in these areas have not traditionally been seen as people who would work at supporting people within the community.

I have mentioned the funding piece before. We will take that back and say there were concerns raised about funding. Is there enough coming and when it comes in, how is it tracked? I hope I have addressed all the questions.

Chairman

I thank Mr. Kane. I know there are a lot of questions. I would echo very much what Deputies Martin and Barry are saying, in that it is not really becoming any clearer as we go along. It is certainly not up to us to tell Mr. Kane whether he should be there or not. He has been selected fairly and we are delighted that he is giving his time as a volunteer.

My and Mr. Kane's paths crossed many years ago. It is good to see him still as committed as ever to doing what he can on a professional and personal basis to improve many lives around the country. In terms of the 48 reports, I actually went through many of them since our last meeting and there was nothing I could disagree with in any of them. I thought all of the recommendations were excellent. Having said that, there was obviously a lot of repetition between them all, which is very understandable because, at the end of the day, we know what is wrong and what needs to be put in place to address it. I include in that comment the report the education committee published only two months ago about all the issues with young people. The question now is how we can get them all onto the same page in terms of implementation. Looking at the terms of reference for the oversight group, it is good that they are quite clear. There has to be a synergy between ourselves and the oversight group. I am interested in knowing a little bit more about points 4 and 5 in particular, in respect of the consultation process. The draft policy will set out the current and future service priorities.

Are there timelines for what the oversight group is working towards to produce that? I believe it is essential that we are part of the process.

It has been mentioned already, but I think creative ways of dealing with mental health, like the #LittleThings campaign, are important. I think it is a brilliant campaign and the more of these campaigns there are, the better. Campaigns that can be run at a local community base are especially important, like men's sheds and Joe.ie. They give a lifeline to people who need it. I imagine many of us have had experience of those and have been able to bear witness to the positive things that they have brought to people along the way.

Mr. Kane mentioned linking in with sports clubs. I think it is great that the GAA has committed to ensuring that there is a mental health officer in every club. This goes back to linking in with the community and it is a major part of the battle. It is about trying to intervene in a positive way as close as possible to where people who have issues are based.

One of the recommendations is about having people with experience of mental health difficulties involved. That is particularly important. Recently, I came across the network that had been set up by the HSE for mental health. I was impressed with it because several of those involved in the network were coming from that place. They had had experience of using the services and part of their mission was to help to identify the gaps. From what I gather, it is stronger in some regions than others. Perhaps Mr. Kane can fill us in on the detail.

I am sorry I missed Mr. Kane's presentation - I got delayed on the way. This is personal to me. It is one of the reasons I am sitting here and giving up my time. I heard some commentary earlier. I believe two heads are better than one and that we should all work together to achieve a real common goal in this area.

Integration and streamlining of the services through cognitive behaviour therapy, wellness centres, the use of primary care centres and our outreach mental health services are important. We should be following the money to follow the patient. If we are to look at it, that is what we should be looking at. It is a matter of how the money follows the patient. That is one of the objectives I am keen to see.

Alcohol was referenced earlier. When we talk about alcohol, we need to consider services for alcohol and gambling addiction, especially how we are funding these services and the counsellors. Many counties, including Galway, do not have outreach for addiction services.

We talk about how we communicate. Mr. Kane has already mentioned Let's Talk. I would be looking at the mental health area with regard to Twitter, whereby people are sitting at home when they want to engage with people. These are positive things that people can do themselves. They can feel engaged and positive in how conversation is being had.

I agree completely with what Deputy Neville has said. Regrettably, not everyone plays GAA, so we need to look at the other therapeutic recovery options. I have in mind dance, yoga, drama and horse-riding. Sometimes, people who might have mental health issues might come from another area of disability. Therefore, their engagement and feeling of participation is most important. Yet again, money follows the patient.

A major part of this arises from how we empower our educators, whether they are educators in education, parents or the person working with young people. Deputy O'Loughlin does not realise it but she created a new buzzword in my head, linked-in. It is a matter of how we can link in all these people and, again, how the money would follow into the school system or the various advocate groups that are promoting positive mental health outcomes.

The most important things we need to identify are the roadblocks and the gatekeepers of finance. Who is preventing this free-flow? If the funding is to be available and we know it needs to get to a particular goal, what is holding it up? That is where I am coming from with much of it.

When we talk about stories, we need to listen. Oisín McConville's story is a powerful one. He tells us that when he started in secondary school he had a gift. The way the educator looked upon him mattered. The suggestion was that he was there because of his gift and his talent at football rather than that he had any ability within his own way to perform in education.

It is a matter of how we speak and engage. Funding may have to go into education to re-train or bring in a particular model. This may be vital for people who are in roles of responsibility and who are moulding and shaping our young people. If we are starting from the beginning, that has to be brought into it as well.

Chairman

Thank you, Deputy Rabbitte. Before you answer, Mr. Kane, there is one thing that I want to be absolutely clear for the members. Are you creating a policy or document that is a roadmap that will be handed to Government at the end of the coming year? Is that your remit?

The second point relates to membership. You spoke about the experts. Really, the experts are the people at the front line. Again, this is something you might address. Who selected the members?

Mr. Hugh Kane

Deputy O'Loughlin asked several questions. The consultation process is something we are going to think about. There has been considerable consultation around developing the new policy for suicide prevention. We have no wish to reinvent consultation that has already taken place in that area. We believe that if we identify some key areas or questions for consultation, it may be the best way to do this. Our initial thoughts included providing for submissions or suggestions about how it might work. We have contemplated trying to workshop them in a way that would invite people to come in and make a short presentation to a group of critical thinkers. This would allow for different views to be run through a process in order to extract the gems we need to use.

It is possible to carry out consultation that ticks the boxes. Anyone can get through 25 boxes, but it is a matter of how to get value and how to use what comes in as well and build on what is in place. That is how we are going to do it.

I was asked about the timeline. We are aiming to try to finish by the end of summer next year. It should take nine months to a year. That is what we are looking for.

Deputy Rabbitte asked about money following the patient. Following our initial deliberation, we are starting to think about outcomes at patient level. The idea is that the resources start to go where people are delivering the outcomes. That is perhaps a way of trying to tighten it up a little as well.

I take the point about this being wider than sport. Whatever people are into is what we are trying to do.

The Chairman asked some other questions. We have been asked to produce a report that will go initially to the management board of the Department of Health and then to the Minister of State with responsibility for mental health and older people, Deputy Jim Daly. From there it will move to the Cabinet sub-committee. These are our terms of reference.

There was a question about how the members were selected. Several people, including me, were looking at the competencies and the type of people required. That is the criteria we have used to try to get a group of people together who can work at a high level.

Chairman

Did you select them, Mr. Kane?

Mr. Hugh Kane

No, it certainly was not me. I would have had an input, as would other colleagues in the Department, when it came to looking at who was involved.

Chairman

Who selected the people? Was it the HSE?

Mr. Hugh Kane

No, absolutely not. The HSE was not involved in the selection process. It was officials from the Department in discussion with me in the context of what we were trying to achieve in trying to get this particular group together. We looked at the competencies and skills needed for this oversight work.

Chairman

We are pushed for time. Thank you for attending today, Mr. Kane and Mr. Murchan. Sorry for the volume of questions. As you can see, the committee members are very interested in the position of the oversight group.

The joint committee went into private session at 11 a.m. and adjourned at 11.15 a.m. until 2 p.m. on Wednesday, 8 November 2017.